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Burden of disease studies in the WHO European Region—a mapping exercise

Burden of disease studies in the WHO European Region—a mapping exercise Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 Burden of disease studies in the WHO European Region 773 ......................................................................................................... The European Journal of Public Health, Vol. 28, No. 4, 773–778 World Health Organization, 2018. The World Health Organization has granted the Publisher permission for the reproduction of this article. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 IGO License (https://creativecommons.org/ licenses/by/3.0/igo/) which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. doi:10.1093/eurpub/cky060 Advance Access published on 25 April 2018 ......................................................................................................... Burden of disease studies in the WHO European Region—a mapping exercise 1 2 2 Mark R. O’Donovan , Christian Gapp , Claudia Stein 1 School of Public Health, University College Cork, Cork, Ireland 2 Division of Information, Evidence, Research, and Innovation, WHO Regional Office for Europe, Copenhagen, Denmark Correspondence: Mark O’Donovan, School of Medicine, National University of Ireland, Galway, Ireland H91TK33, Tel: +353 (0) 863014111, fax: N/A, e-mail: mark.odonovan@nuigalway.ie Background: The World Health Organization (WHO) and the Institute for Health Metrics and Evaluation (IHME) have produced numerous global burden of disease (GBD) estimates since the 1990s, using disability-adjusted life- years (DALYs). Here we attempt to identify studies that have either independent DALY estimates or build on the work of WHO and IHME, for the WHO European Region, categorize them by scope of disease analysis and geographic coverage, and briefly compare their methodology (age weighting, discounting and disability weights). Methods: Google and Google Scholar were used with the search terms ‘DALY’, ‘national burden of disease’, Member State names and researcher’s names, covering all years. Studies were categorized as: ‘specific’ (fewer than five disease categories or just risk factors for a single country), ‘specific, multicountry’ (fewer than five disease categories or just risk factors for more than one country), ‘extensive’ (covering five or more but not all disease categories for one country), ‘full, sub country’ (covering all relevant disease categories for part of one country) and ‘full, country’ (covering all relevant disease categories for one country). Results: A total of 198 studies were identified: 143 ‘specific’, 26 ‘specific, multicountry’, 7 ‘extensive’, 10 ‘full, sub country’ and 12 ‘full, country’ [England (1), Estonia (2), France (1), Romania (1), Serbia (1), Spain (3), Sweden (2) and Turkey (1)]. About 5 (20%) of the 25 examinable ‘extensive’, ‘full, sub country’ and ‘full, country’ studies calculated DALYs using GBD 2010 methodology. Conclusions: Independent burden of diseases studies in Europe have been located, and categorized by scope of disease analysis and geographic coverage. Methodological choices varied between independent ‘full, country’ studies. ......................................................................................................... analogue scale (VAS), time trade-off (TTO), person trade-off (PTO) Introduction or standard gamble (SG). Various DWs have been calculated, e.g. in 9,10 11 he burden of disease (BoD) method analyzes the impact of the global burden of disease (GBD) studies, the Netherlands T disease upon populations through a combination of mortality and Estonia. DWs tend to have reasonably high level of and morbidity measures into a single summary statistic of agreement across populations for most conditions, but valuation 13,14 population health. A summary measure frequently used by the methods vary significantly. World Health Organization (WHO) and the Institute for Health In early DALY estimates two additional social weights, discount- Metrics and Evaluation (IHME) is the disability-adjusted life-year ing and age weighting, were widely used. With discounting, less (DALY). DALYs quantify disease burden as a health gap; the value is applied to future life-years than those lived today, based difference between a hypothetical ideal state of health and on the social preference of a healthy year now rather than at a wellbeing, and the actual observed health status. ‘Disability’ in later date. Age weighting intends to adjust for altering levels of this context refers to any less than ideal health status. dependency with age, as well as possible societal preference for DALYs are calculated through the addition of years of life lost particular ages of life. Ages 0–38 years were favoured by the appli- (YLL) and years lost due to disability (YLD) and details of their cation of both these social weights. However, following consider- 3–5 15–17 calculation are provided elsewhere. YLL is an incidence-based able criticism both age weighting and discounting have been 6–8 measure consisting of the number of deaths multiplied by the dropped from recent WHO/IHME calculations. standard life expectancy at the age that each death occurred As a single number representative of both societal perceptions of (expected life remaining). YLD is a measure of how many years of morbidity and objective measures of mortality, DALYs are a clear, healthy life are lost due to time lived in a health status other than concise and versatile measure of impact which can be applied to 18 19 20 21 optimal health (i.e. disability). Originally, new incident cases were diseases, risk factors, interventions and adverse events. They used to maintain consistency with YLL, but more recent methods can also be easily utilized for risk-benefit analysis as well as 4,6–8 23,24 use prevalence data. cost-effectiveness studies. Since DALYs are rooted in societal YLD calculation relies upon disability weights (DWs) which are preferences they can also be considered an important step to- socially derived values based on how the majority of people perceive wards incorporating public opinion in health decision making, living with a disease or condition for a one year period, where 0 is and making decisions more representative of population optimal health and 1 is equivalent to death. These DWs only perspectives. represent societal preferences about living with a condition and do DALYs were initially conceptualized as the health indicator for the not represent utility, closeness to death, capabilities or the worth of first GBD study (GBD 1990) which was directed by Christopher individuals. DW calculation involves a standardized description of Murray and Alan Lopez under a joint exercise by the WHO and 25,26 the health states (e.g. EQ-5 D) and valuation methods such as visual the World Bank. Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 774 European Journal of Public Health This original GBD study produced estimates using both ‘adjusted texts where available. To be eligible for inclusion in this review, DALYs’ (3% discounting and age weighting) and ‘age-weighted publications had to satisfy the following inclusion criteria. The DALYs’ (no discounting, age weighting). Following this study study: 6,7 2 the WHO and more recently the IHME have produced (i) uses the DALY metric, providing DALY estimates for a numerous GBD updates. The WHO has been producing various population; versions of adjusted DALYs, unadjusted DALYs (no discounting, (ii) includes a geographic area within the WHO European Region; no age weighting) and discounted DALYs (3% discounting, no age (iii) is the original publication of the estimates (or the earliest weighting) for the years 2000–12, but since the GBD 2010 study located); and 6–8 unadjusted DALYs have become the established approach. (iv) builds on or modifies WHO and IHME estimates, or is inde- pendent research that does not include WHO or IHME However, in addition to WHO and IHME estimates many other estimates. independent studies must have been conducted but their number, scope of disease analysis and methodology remain largely unknown. Publications with original BoD estimates for any part of the Previous literature reviews have provided a snapshot of a vast and European Region were eligible for inclusion; these included Global varied literature with considerable variation in the use of discount- studies, as well as cost-effectiveness studies that calculated DALY ing, age weighting, DWs, reference life tables, incidence or 23,24 rates for a European geographic area as part of their analysis. prevalence measures and methods handling missing and poorly Studies that did not meet one or more of the above criteria were not coded data. included in this review. In light of the many potential benefits of measuring BoD and the unknown status and methodology of current independent BoD Classification of studies studies we decided to identify these studies for the WHO European Region, and to map out their extent, scope of disease A first screening of the studies revealed main differences in the scope analysis, geographic coverage and basic methodological choices (in of diseases and geographic coverage. Therefore, in a second step, the case of larger BoD studies). This will provide us with an approxi- studies in this review are classified into five groups based on the mation of the current level of BoD usage, capacity, and comparabil- scope of disease analysis and their geographic coverage as follows: ity, hopefully inspire future research, draw attention to the existing (i) ‘specific’ (covering fewer than five disease categories or just literature and promote the use of agreed standardized methodology risk factors for all/part of one European country); for local and comparable estimates. (ii) ‘specific, multicountry’ (covering fewer than five disease categories or just risk factors for all/parts of more than one European country); Methods (iii) ‘extensive’ (covering five or more but not all disease categories for all/part of one European country); Due to the different settings in which BoD research is conducted (by (iv) ‘full, sub country’ (covering all relevant disease categories and national governments, private sector researchers and academic representative of part of one European country, e.g. a region, settings), and the spread of BoD studies across different types of city or population subgroup); and journals and databases, it appeared likely that using conventional (v) ‘full, country’ (covering all relevant disease categories and rep- search strategies of PubMed, Scopus and similar would resentative of the whole of one European country). underrepresent this literature. To address this concern and increase the sensitivity of the search we moved away from specialized The term ‘country’ here can refer to just one constituent country academic databases and instead used Google and Google Scholar as or territory in the case of larger sovereign countries. This means, e.g. our search engines. that a study in Denmark would not need to include the other two Three main searches were carried out between April and July constituent territories (Greenland and the Faroe Islands) to be 2016, as summarized in table 1. The first used the search terms categorized as covering a whole country and that a full study in ‘Member State name’, ‘national burden of disease’ and ‘DALY’ for England, Wales, Scotland, or Northern Ireland would be categorized each of the 53 Member States in the Region on both Google and as a ‘full, country study’. This decision was made since research Google Scholar. Unlike the other two searches this first search was tends to take place at the constituent country or territory level; mainly concerned with finding full national/country studies and we e.g. in UK responsibility for health and public health has been limited our search engines to only show studies since the year 2000. devolved to its constituent countries since 1998. Since the second GBD study and WHO’s national BoD manual were The term ‘disease category’ here refers to any of the 23 main cause not published until 2001 we felt that most studies before this time categories utilized in recent WHO Global Health Estimates publica- 6,7 would be methodological discussion papers, and that any independ- tions. In the case of research examining just risk factors (e.g. BoD ent full national studies in this period should be cited in later caused by environmental exposures) we have classified them as 4,9,28 publications. ‘specific’ studies since they focus on a specific category of risk The second search used the search terms ‘burden of disease’ and factors. In doing so we are categorizing studies in terms of com- ‘Member State name’ on Google. The third search used the names of pleteness of disease/risk coverage, and are not referring to the quality researchers affiliated with BoD research or methodology, using the or quantity of work involved. search terms ‘DALY’ and author: ‘full name’ or ‘DALY’ and author: ‘surname’. These names were obtained via personal communication Analysis of methodological choices or from studies found within all three searches. Finally we conducted a brief methodological analysis of ‘extensive’, In addition, reference checks were performed on all accessible ‘full, sub country’ and ‘full, country’ studies looking at the use of age eligible studies. These checks identified many additional publications weighting, discounting, and DWs (see Supplementary content 1). that were eligible for inclusion in this review and these are all They were classified into the four following categories: included under the applicable search in our results. Reference checks were especially helpful in locating earlier series of burden- (i) ‘adjusted DALYs’ (3% discounting and age weighting); calculating reports and poorly indexed studies. (ii) ‘discounted DALYs’ (3% discounting, no age weighting); (iii) ‘age-weighted DALYs’ (no discounting, age weighting); and (iv) ‘unadjusted DALYs’ (no discounting, no age weighting). Inclusion criteria for studies Based on this review’s inclusion criteria eligible studies were DWs were classed as either GBD DWs (including modified and identified from the above search hits by reading abstracts or full updated), or national DWs (Dutch and Estonian). Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 Burden of disease studies in the WHO European Region 775 Table 1 Summary of study searches conducted (April–July 2016) No. Search engine(s) Search terms Restriction(s) Search numbers 1 Google and Google ‘Member State name’, ‘national Since year 2000 106 searches with 72–538 Scholar burden of disease’, ‘DALY’ hits each 2 Google ‘burden of disease’, ‘Member Default ‘omit similar 53 searches with 142–277 State name’ results’ enabled hits each 3a Google Scholar ‘DALY’, author: ‘full name’ None >600 researchers 0–104 hits each 3b Google Scholar ‘DALY’, author: ‘surname’ Only first 100 search hits >100 researchers 0–6790 where >100 hits hits each Figure 1 Number of burden of disease studies published each year. Colours of each bar provide a breakdown of the types of studies conducted each year as follows: light grey (leftmost) bar—specific studies; dark grey (second from left) bar—specific, multicountry studies; very dark grey (third from left) bar—extensive studies; darkest grey (fourth from left) bar—full, sub country studies; black (fifth from left) bar—full, country studies; numbered white bar with a black outline (rightmost)—total number of BoD studies Please note that the online searches for this review were conducted between April and July 2016. up to the latest full year of 2015. This is mainly due to an increase in the number of ‘specific’ and ‘specific, multicountry’ studies. (Note: Results the results for 2016 are not representative of the full year.) Number of studies identified Geographic coverage From the three searches outlined in table 1, including reference checks, a total of 198 studies were identified that were eligible for Of the 26 specific, multicountry studies, 17 studied all/most of the inclusion in this review: 63 from search 1, 51 from search 2 and 84 WHO European Region (>30 Member States) and 12 of these were from search 3. global studies. The other nine studied between two and eight Member States. Excluding the 17 specific, multicountry studies that cover all/most Study types of the Region, publications were still found for about half of About 85% (169/198) of studies looked at a small range of diseases Member States in the Region: 26 of 53. As shown in figure 2 or just risk factors; of these, 143 involved a population from a single the largest number was in the Netherlands (75), followed by Spain country (‘specific’) and 26 spanned 2 or more Member States (21), UK (17), Denmark (15), Belgium (10), Portugal (10), Sweden (‘specific, multicountry’). No multicountry studies looked at more (8), Germany (7), France (6), Norway (6), Serbia (6), Italy than two disease categories or risk factors. (5), Austria (4), Poland (4), Bulgaria (3), Estonia (3), Ireland (3), The remaining 15% (29/198) of studies looked at a large number Azerbaijan (2), Finland (2), Slovenia (2), Switzerland (2), Albania of or all main diseases; of these, 7 looked at 5 or more disease (1), Greece (1), Latvia (1), Romania (1) and Turkey (1). [Note: the categories (‘extensive’) and 22 covered all disease categories. sum of these studies adds up to more than the total number of Of the 22 looking at all disease categories, 12 covered a studies (N = 198) owing to inclusion of the nine smaller ‘specific, full country population (‘full, country’) and 10 were for a multicountry’ studies under multiple Member States.] population below country representation (‘full, sub country’). A Full, country studies were found for England (1), Estonia (2), geographic breakdown of the numbers and types of studies is France (1), Romania (1), Serbia (1), Spain (3), Sweden (2) and shown in figure 2. Turkey (1). Years of publication Methodological choices As seen in figure 1 the earliest study located was published in 1997, Of the 29 ‘extensive’, ‘full, sub country’ and ‘full, country’ studies 25 with a steady increase in the number of studies published each year had enough available data to examine their methodology (two Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 776 European Journal of Public Health Figure 2 Map of the WHO European Region showing the total number of burden of disease studies conducted for each Member State and the most comprehensive type of study for each. Colours illustrate the most comprehensive type of study for each Member State as follows: light grey shading with black text—specific studies (including multicountry ); dark grey shading with black text—extensive study; dark grey shading with white text—full, sub country study; black shading with white text—full, country study Please note that specific multicountry studies that cover over half the Member States (N =17) are not included on this map. Please note that the full, country study for UK only covers England, not the whole of UK unavailable online, two unexaminable owing to language barriers). examining all disease categories were conducted in Spain, with a Including published, partly-published and unpublished analysis total of seven: three full, country studies and four full, sub some of the 25 studies include more than one of the DALY country studies. Others, such as a full, country study in France or categories outlined in our methods section (adjusted DALYs, full, sub country studies in Azerbaijan and Portugal, remain rarely discounted DALYs, age-weighted DALYs and unadjusted DALYs). cited. For these DALY categories, 20 studies (80%) include 1, 4 studies The majority of BoD publications comes from the Netherlands, (16%) include 2 and 1 study (4%) includes 3 DALY categories where the methodology is highly integrated into national disease 31,32 (31 DALY category estimates in total). Including studies under all reporting in many different specific areas. However, these relevant categories: 17 studies (68%) calculated adjusted DALYs, 3 include only three extensive studies and no full studies. This studies (12%) calculated discounted DALYs, 2 studies (8%) approach of using BoD analysis in a fragmented topic-specific calculated age-weighted DALYs and 9 studies (36%) calculated manner (seen in the Netherlands and across the European Region) unadjusted DALYs. is generally not ideal, as it tends to overestimate the impact of In total five studies (20%) used national DWs, with two using studied conditions and excludes other important diseases and risk Estonian weights and three using Dutch weights. Four of these used factors. Only full BoD studies avoid large over-attributions of unadjusted DALYs, and all five were published before the GBD burden to specific individual conditions and give more accurate, 2010 study when this approach became the norm for GBD balanced estimates. In our view, full, country and full, sub 6,8 estimatimation. country studies provide the most robust data for policy. In total five (20%) used unadjusted DALYs with GBD DWs and Our analysis shows that BoD studies were carried out primarily in four of these were published before the GBD 2010 study. the western part of the Region (see figure 2) and highlights areas without independent BoD publications. We hope that these gaps in the literature will soon be addressed as they would allow for the use Discussion of local data for the estimation of BoD without the need to ‘borrow strength’ from data of other countries. This paper has mapped the extent, scope of disease analysis and While this review makes important observations it does have a geographic coverage of BoD research for the WHO European number of limitations. First, the terminology of search terms and Region until mid-2016. Since this date additional studies may their combinations was intentionally narrow—‘burden of disease’ have been published, one example being the comprehensive Scottish BoD study. was used but ‘disease burden’ was not. A preliminary test showed that the latter phrase was too unspecific and yielded too many We were surprised to find nearly 200 BoD studies for the Region, but these were mainly specific in focus, examining a limited number studies that in the end were not dealing with BoD using DALYs. Longer, more robust, search terms could have been used, as well as of diseases or just risk factors. About 85% of publications used DALYs for these specific research topics. Nevertheless, this illustrates search engines other than Google and Google Scholar. However, that BoD methods are widely used and valued throughout the given the large number of searches and reference checks Region by numerous researchers. Most of the publications conducted we consider these limitations minor. 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Bilthoven: National Institute for Public Health data-and-evidence/european-health-information-initiative-ehii (21 November 2017, and the Environment, 2014. Report No.: RIVM Rapport 2014-0069. date last accessed). 33 Jamison DT. Foreword to the global burden of disease and injury series. In: Murray CJL, Lopez AD, editors. The Global Burden of Disease: A Comprehensive ......................................................................................................... The European Journal of Public Health, Vol. 28, No. 4, 778–783 The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckx219 Advance Access published on 16 January 2018 ......................................................................................................... Physical activity, weight and functional limitations in elderly Spanish people: the National Health Survey (2009–2014) 1 2 3 Pedro A. Latorre-Roma´ n , Jose´ A. Laredo-Aguilera , Felipe Garcı´a-Pinillos , 4 2 Vı´ctor M. Soto-Hermoso , Juan M. Carmona-Torres 1 Department of Corporal Expression, University of Jaen, Jaen, Spain 2 Department of Nurse, University of Castilla La-Mancha, Ciudad Real, Spain 3 Department of Physical Education, Sport and Recreation, Universidad de La Frontera, Temuco, Chile 4 Department of Physical and Sports Education, University of Granada, Granada, Spain ´ ´ Correspondence: Jose Alberto Laredo-Aguilera, Av. Real Fabrica de Sedas, s/n, 45600 Talavera de la Reina, Toledo, Tel: +34 690384737, e-mail: jalaredo88@gmail.com Background: The purpose of this study was to analyze physical activity (PA), functional limitations, weight status, self-perceived health status and disease or chronic health problems in older people aged 65 and over using the European Health Survey in Spain (EHSS) conducted one in 2009 and one in 2014. Methods: This study included 12,546 older people, 6026 [2330 men and 3696 women; age (Mean, SD) =75.61  7.11 years old] in 2009 and 6520 [2624 men and 3896 women; age (Mean, SD) =75.90  7.59 years old] in 2014. The sample was divided into three age groups: 65–74 years old, 75–84 years old and 85 years old. Results: In 2014, participants exhibited lower values for moderate PA, and self-perceived health status compared to 2009. Moreover, in 2014 more people with disease or chronic health problems, and severe difficulty walking 500 m without assistance were found and severe difficulty going up and down 12 stairs than people in 2009. In relation to weight status there were no significant differences between older people in 2009 and 2014. Conclusions: From 2009 to 2014, the PA levels of Spanish older people have decreased, while the BMI has not increased. That fact is in consonance with a worst perception of health status in 2014 and with an increase of their disease levels. The current data highlight the importance of incorporating exercise programmes at an early stage of ageing in order to preserve physical per- formance, and to prevent the negative consequences of ageing. ......................................................................................................... associated with increased incidence of type 2 diabetes, cardiovascu- Introduction 7 8 lar disease and risk of falls. estern Europe has one of the world’s oldest populations. In Obesity and physical inactivity are major universal public health Spain, life expectancy is 78.9 years for men and 84.9 years for concerns in older people and physical activity (PA) has shown the women. Ageing has been associated with frailty and functional largest impact on survival, with the strongest inverse relationship limitation due to three factors: an irreversible biological process, between body mass index (BMI) and mortality. Promotion of deconditioning due to a sedentary lifestyle and comorbidity effects. regular PA is one of the main non-pharmaceutical measures Along with ageing, there is impairment in the functional reserve, proposed for older people, who often show a low rate of PA. increasing sensitivity to external aggressions causing fragility, The PA has been widely recommended due to its positive effects sarcopenia, falls, disability and hospitalization, with a deterioration on the maintenance and/or increase in skeletal muscle mass and 4 5 5,11 in quality of life and physical fitness. These decrements have been strength, and in aerobic fitness. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Public Health Oxford University Press

Burden of disease studies in the WHO European Region—a mapping exercise

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Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 Burden of disease studies in the WHO European Region 773 ......................................................................................................... The European Journal of Public Health, Vol. 28, No. 4, 773–778 World Health Organization, 2018. The World Health Organization has granted the Publisher permission for the reproduction of this article. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 IGO License (https://creativecommons.org/ licenses/by/3.0/igo/) which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. doi:10.1093/eurpub/cky060 Advance Access published on 25 April 2018 ......................................................................................................... Burden of disease studies in the WHO European Region—a mapping exercise 1 2 2 Mark R. O’Donovan , Christian Gapp , Claudia Stein 1 School of Public Health, University College Cork, Cork, Ireland 2 Division of Information, Evidence, Research, and Innovation, WHO Regional Office for Europe, Copenhagen, Denmark Correspondence: Mark O’Donovan, School of Medicine, National University of Ireland, Galway, Ireland H91TK33, Tel: +353 (0) 863014111, fax: N/A, e-mail: mark.odonovan@nuigalway.ie Background: The World Health Organization (WHO) and the Institute for Health Metrics and Evaluation (IHME) have produced numerous global burden of disease (GBD) estimates since the 1990s, using disability-adjusted life- years (DALYs). Here we attempt to identify studies that have either independent DALY estimates or build on the work of WHO and IHME, for the WHO European Region, categorize them by scope of disease analysis and geographic coverage, and briefly compare their methodology (age weighting, discounting and disability weights). Methods: Google and Google Scholar were used with the search terms ‘DALY’, ‘national burden of disease’, Member State names and researcher’s names, covering all years. Studies were categorized as: ‘specific’ (fewer than five disease categories or just risk factors for a single country), ‘specific, multicountry’ (fewer than five disease categories or just risk factors for more than one country), ‘extensive’ (covering five or more but not all disease categories for one country), ‘full, sub country’ (covering all relevant disease categories for part of one country) and ‘full, country’ (covering all relevant disease categories for one country). Results: A total of 198 studies were identified: 143 ‘specific’, 26 ‘specific, multicountry’, 7 ‘extensive’, 10 ‘full, sub country’ and 12 ‘full, country’ [England (1), Estonia (2), France (1), Romania (1), Serbia (1), Spain (3), Sweden (2) and Turkey (1)]. About 5 (20%) of the 25 examinable ‘extensive’, ‘full, sub country’ and ‘full, country’ studies calculated DALYs using GBD 2010 methodology. Conclusions: Independent burden of diseases studies in Europe have been located, and categorized by scope of disease analysis and geographic coverage. Methodological choices varied between independent ‘full, country’ studies. ......................................................................................................... analogue scale (VAS), time trade-off (TTO), person trade-off (PTO) Introduction or standard gamble (SG). Various DWs have been calculated, e.g. in 9,10 11 he burden of disease (BoD) method analyzes the impact of the global burden of disease (GBD) studies, the Netherlands T disease upon populations through a combination of mortality and Estonia. DWs tend to have reasonably high level of and morbidity measures into a single summary statistic of agreement across populations for most conditions, but valuation 13,14 population health. A summary measure frequently used by the methods vary significantly. World Health Organization (WHO) and the Institute for Health In early DALY estimates two additional social weights, discount- Metrics and Evaluation (IHME) is the disability-adjusted life-year ing and age weighting, were widely used. With discounting, less (DALY). DALYs quantify disease burden as a health gap; the value is applied to future life-years than those lived today, based difference between a hypothetical ideal state of health and on the social preference of a healthy year now rather than at a wellbeing, and the actual observed health status. ‘Disability’ in later date. Age weighting intends to adjust for altering levels of this context refers to any less than ideal health status. dependency with age, as well as possible societal preference for DALYs are calculated through the addition of years of life lost particular ages of life. Ages 0–38 years were favoured by the appli- (YLL) and years lost due to disability (YLD) and details of their cation of both these social weights. However, following consider- 3–5 15–17 calculation are provided elsewhere. YLL is an incidence-based able criticism both age weighting and discounting have been 6–8 measure consisting of the number of deaths multiplied by the dropped from recent WHO/IHME calculations. standard life expectancy at the age that each death occurred As a single number representative of both societal perceptions of (expected life remaining). YLD is a measure of how many years of morbidity and objective measures of mortality, DALYs are a clear, healthy life are lost due to time lived in a health status other than concise and versatile measure of impact which can be applied to 18 19 20 21 optimal health (i.e. disability). Originally, new incident cases were diseases, risk factors, interventions and adverse events. They used to maintain consistency with YLL, but more recent methods can also be easily utilized for risk-benefit analysis as well as 4,6–8 23,24 use prevalence data. cost-effectiveness studies. Since DALYs are rooted in societal YLD calculation relies upon disability weights (DWs) which are preferences they can also be considered an important step to- socially derived values based on how the majority of people perceive wards incorporating public opinion in health decision making, living with a disease or condition for a one year period, where 0 is and making decisions more representative of population optimal health and 1 is equivalent to death. These DWs only perspectives. represent societal preferences about living with a condition and do DALYs were initially conceptualized as the health indicator for the not represent utility, closeness to death, capabilities or the worth of first GBD study (GBD 1990) which was directed by Christopher individuals. DW calculation involves a standardized description of Murray and Alan Lopez under a joint exercise by the WHO and 25,26 the health states (e.g. EQ-5 D) and valuation methods such as visual the World Bank. Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 774 European Journal of Public Health This original GBD study produced estimates using both ‘adjusted texts where available. To be eligible for inclusion in this review, DALYs’ (3% discounting and age weighting) and ‘age-weighted publications had to satisfy the following inclusion criteria. The DALYs’ (no discounting, age weighting). Following this study study: 6,7 2 the WHO and more recently the IHME have produced (i) uses the DALY metric, providing DALY estimates for a numerous GBD updates. The WHO has been producing various population; versions of adjusted DALYs, unadjusted DALYs (no discounting, (ii) includes a geographic area within the WHO European Region; no age weighting) and discounted DALYs (3% discounting, no age (iii) is the original publication of the estimates (or the earliest weighting) for the years 2000–12, but since the GBD 2010 study located); and 6–8 unadjusted DALYs have become the established approach. (iv) builds on or modifies WHO and IHME estimates, or is inde- pendent research that does not include WHO or IHME However, in addition to WHO and IHME estimates many other estimates. independent studies must have been conducted but their number, scope of disease analysis and methodology remain largely unknown. Publications with original BoD estimates for any part of the Previous literature reviews have provided a snapshot of a vast and European Region were eligible for inclusion; these included Global varied literature with considerable variation in the use of discount- studies, as well as cost-effectiveness studies that calculated DALY ing, age weighting, DWs, reference life tables, incidence or 23,24 rates for a European geographic area as part of their analysis. prevalence measures and methods handling missing and poorly Studies that did not meet one or more of the above criteria were not coded data. included in this review. In light of the many potential benefits of measuring BoD and the unknown status and methodology of current independent BoD Classification of studies studies we decided to identify these studies for the WHO European Region, and to map out their extent, scope of disease A first screening of the studies revealed main differences in the scope analysis, geographic coverage and basic methodological choices (in of diseases and geographic coverage. Therefore, in a second step, the case of larger BoD studies). This will provide us with an approxi- studies in this review are classified into five groups based on the mation of the current level of BoD usage, capacity, and comparabil- scope of disease analysis and their geographic coverage as follows: ity, hopefully inspire future research, draw attention to the existing (i) ‘specific’ (covering fewer than five disease categories or just literature and promote the use of agreed standardized methodology risk factors for all/part of one European country); for local and comparable estimates. (ii) ‘specific, multicountry’ (covering fewer than five disease categories or just risk factors for all/parts of more than one European country); Methods (iii) ‘extensive’ (covering five or more but not all disease categories for all/part of one European country); Due to the different settings in which BoD research is conducted (by (iv) ‘full, sub country’ (covering all relevant disease categories and national governments, private sector researchers and academic representative of part of one European country, e.g. a region, settings), and the spread of BoD studies across different types of city or population subgroup); and journals and databases, it appeared likely that using conventional (v) ‘full, country’ (covering all relevant disease categories and rep- search strategies of PubMed, Scopus and similar would resentative of the whole of one European country). underrepresent this literature. To address this concern and increase the sensitivity of the search we moved away from specialized The term ‘country’ here can refer to just one constituent country academic databases and instead used Google and Google Scholar as or territory in the case of larger sovereign countries. This means, e.g. our search engines. that a study in Denmark would not need to include the other two Three main searches were carried out between April and July constituent territories (Greenland and the Faroe Islands) to be 2016, as summarized in table 1. The first used the search terms categorized as covering a whole country and that a full study in ‘Member State name’, ‘national burden of disease’ and ‘DALY’ for England, Wales, Scotland, or Northern Ireland would be categorized each of the 53 Member States in the Region on both Google and as a ‘full, country study’. This decision was made since research Google Scholar. Unlike the other two searches this first search was tends to take place at the constituent country or territory level; mainly concerned with finding full national/country studies and we e.g. in UK responsibility for health and public health has been limited our search engines to only show studies since the year 2000. devolved to its constituent countries since 1998. Since the second GBD study and WHO’s national BoD manual were The term ‘disease category’ here refers to any of the 23 main cause not published until 2001 we felt that most studies before this time categories utilized in recent WHO Global Health Estimates publica- 6,7 would be methodological discussion papers, and that any independ- tions. In the case of research examining just risk factors (e.g. BoD ent full national studies in this period should be cited in later caused by environmental exposures) we have classified them as 4,9,28 publications. ‘specific’ studies since they focus on a specific category of risk The second search used the search terms ‘burden of disease’ and factors. In doing so we are categorizing studies in terms of com- ‘Member State name’ on Google. The third search used the names of pleteness of disease/risk coverage, and are not referring to the quality researchers affiliated with BoD research or methodology, using the or quantity of work involved. search terms ‘DALY’ and author: ‘full name’ or ‘DALY’ and author: ‘surname’. These names were obtained via personal communication Analysis of methodological choices or from studies found within all three searches. Finally we conducted a brief methodological analysis of ‘extensive’, In addition, reference checks were performed on all accessible ‘full, sub country’ and ‘full, country’ studies looking at the use of age eligible studies. These checks identified many additional publications weighting, discounting, and DWs (see Supplementary content 1). that were eligible for inclusion in this review and these are all They were classified into the four following categories: included under the applicable search in our results. Reference checks were especially helpful in locating earlier series of burden- (i) ‘adjusted DALYs’ (3% discounting and age weighting); calculating reports and poorly indexed studies. (ii) ‘discounted DALYs’ (3% discounting, no age weighting); (iii) ‘age-weighted DALYs’ (no discounting, age weighting); and (iv) ‘unadjusted DALYs’ (no discounting, no age weighting). Inclusion criteria for studies Based on this review’s inclusion criteria eligible studies were DWs were classed as either GBD DWs (including modified and identified from the above search hits by reading abstracts or full updated), or national DWs (Dutch and Estonian). Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 Burden of disease studies in the WHO European Region 775 Table 1 Summary of study searches conducted (April–July 2016) No. Search engine(s) Search terms Restriction(s) Search numbers 1 Google and Google ‘Member State name’, ‘national Since year 2000 106 searches with 72–538 Scholar burden of disease’, ‘DALY’ hits each 2 Google ‘burden of disease’, ‘Member Default ‘omit similar 53 searches with 142–277 State name’ results’ enabled hits each 3a Google Scholar ‘DALY’, author: ‘full name’ None >600 researchers 0–104 hits each 3b Google Scholar ‘DALY’, author: ‘surname’ Only first 100 search hits >100 researchers 0–6790 where >100 hits hits each Figure 1 Number of burden of disease studies published each year. Colours of each bar provide a breakdown of the types of studies conducted each year as follows: light grey (leftmost) bar—specific studies; dark grey (second from left) bar—specific, multicountry studies; very dark grey (third from left) bar—extensive studies; darkest grey (fourth from left) bar—full, sub country studies; black (fifth from left) bar—full, country studies; numbered white bar with a black outline (rightmost)—total number of BoD studies Please note that the online searches for this review were conducted between April and July 2016. up to the latest full year of 2015. This is mainly due to an increase in the number of ‘specific’ and ‘specific, multicountry’ studies. (Note: Results the results for 2016 are not representative of the full year.) Number of studies identified Geographic coverage From the three searches outlined in table 1, including reference checks, a total of 198 studies were identified that were eligible for Of the 26 specific, multicountry studies, 17 studied all/most of the inclusion in this review: 63 from search 1, 51 from search 2 and 84 WHO European Region (>30 Member States) and 12 of these were from search 3. global studies. The other nine studied between two and eight Member States. Excluding the 17 specific, multicountry studies that cover all/most Study types of the Region, publications were still found for about half of About 85% (169/198) of studies looked at a small range of diseases Member States in the Region: 26 of 53. As shown in figure 2 or just risk factors; of these, 143 involved a population from a single the largest number was in the Netherlands (75), followed by Spain country (‘specific’) and 26 spanned 2 or more Member States (21), UK (17), Denmark (15), Belgium (10), Portugal (10), Sweden (‘specific, multicountry’). No multicountry studies looked at more (8), Germany (7), France (6), Norway (6), Serbia (6), Italy than two disease categories or risk factors. (5), Austria (4), Poland (4), Bulgaria (3), Estonia (3), Ireland (3), The remaining 15% (29/198) of studies looked at a large number Azerbaijan (2), Finland (2), Slovenia (2), Switzerland (2), Albania of or all main diseases; of these, 7 looked at 5 or more disease (1), Greece (1), Latvia (1), Romania (1) and Turkey (1). [Note: the categories (‘extensive’) and 22 covered all disease categories. sum of these studies adds up to more than the total number of Of the 22 looking at all disease categories, 12 covered a studies (N = 198) owing to inclusion of the nine smaller ‘specific, full country population (‘full, country’) and 10 were for a multicountry’ studies under multiple Member States.] population below country representation (‘full, sub country’). A Full, country studies were found for England (1), Estonia (2), geographic breakdown of the numbers and types of studies is France (1), Romania (1), Serbia (1), Spain (3), Sweden (2) and shown in figure 2. Turkey (1). Years of publication Methodological choices As seen in figure 1 the earliest study located was published in 1997, Of the 29 ‘extensive’, ‘full, sub country’ and ‘full, country’ studies 25 with a steady increase in the number of studies published each year had enough available data to examine their methodology (two Downloaded from https://academic.oup.com/eurpub/article/28/4/773/4985716 by DeepDyve user on 14 July 2022 776 European Journal of Public Health Figure 2 Map of the WHO European Region showing the total number of burden of disease studies conducted for each Member State and the most comprehensive type of study for each. Colours illustrate the most comprehensive type of study for each Member State as follows: light grey shading with black text—specific studies (including multicountry ); dark grey shading with black text—extensive study; dark grey shading with white text—full, sub country study; black shading with white text—full, country study Please note that specific multicountry studies that cover over half the Member States (N =17) are not included on this map. Please note that the full, country study for UK only covers England, not the whole of UK unavailable online, two unexaminable owing to language barriers). examining all disease categories were conducted in Spain, with a Including published, partly-published and unpublished analysis total of seven: three full, country studies and four full, sub some of the 25 studies include more than one of the DALY country studies. Others, such as a full, country study in France or categories outlined in our methods section (adjusted DALYs, full, sub country studies in Azerbaijan and Portugal, remain rarely discounted DALYs, age-weighted DALYs and unadjusted DALYs). cited. For these DALY categories, 20 studies (80%) include 1, 4 studies The majority of BoD publications comes from the Netherlands, (16%) include 2 and 1 study (4%) includes 3 DALY categories where the methodology is highly integrated into national disease 31,32 (31 DALY category estimates in total). Including studies under all reporting in many different specific areas. However, these relevant categories: 17 studies (68%) calculated adjusted DALYs, 3 include only three extensive studies and no full studies. This studies (12%) calculated discounted DALYs, 2 studies (8%) approach of using BoD analysis in a fragmented topic-specific calculated age-weighted DALYs and 9 studies (36%) calculated manner (seen in the Netherlands and across the European Region) unadjusted DALYs. is generally not ideal, as it tends to overestimate the impact of In total five studies (20%) used national DWs, with two using studied conditions and excludes other important diseases and risk Estonian weights and three using Dutch weights. Four of these used factors. Only full BoD studies avoid large over-attributions of unadjusted DALYs, and all five were published before the GBD burden to specific individual conditions and give more accurate, 2010 study when this approach became the norm for GBD balanced estimates. In our view, full, country and full, sub 6,8 estimatimation. country studies provide the most robust data for policy. In total five (20%) used unadjusted DALYs with GBD DWs and Our analysis shows that BoD studies were carried out primarily in four of these were published before the GBD 2010 study. the western part of the Region (see figure 2) and highlights areas without independent BoD publications. We hope that these gaps in the literature will soon be addressed as they would allow for the use Discussion of local data for the estimation of BoD without the need to ‘borrow strength’ from data of other countries. This paper has mapped the extent, scope of disease analysis and While this review makes important observations it does have a geographic coverage of BoD research for the WHO European number of limitations. First, the terminology of search terms and Region until mid-2016. Since this date additional studies may their combinations was intentionally narrow—‘burden of disease’ have been published, one example being the comprehensive Scottish BoD study. was used but ‘disease burden’ was not. A preliminary test showed that the latter phrase was too unspecific and yielded too many We were surprised to find nearly 200 BoD studies for the Region, but these were mainly specific in focus, examining a limited number studies that in the end were not dealing with BoD using DALYs. Longer, more robust, search terms could have been used, as well as of diseases or just risk factors. About 85% of publications used DALYs for these specific research topics. Nevertheless, this illustrates search engines other than Google and Google Scholar. However, that BoD methods are widely used and valued throughout the given the large number of searches and reference checks Region by numerous researchers. Most of the publications conducted we consider these limitations minor. 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Bilthoven: National Institute for Public Health data-and-evidence/european-health-information-initiative-ehii (21 November 2017, and the Environment, 2014. Report No.: RIVM Rapport 2014-0069. date last accessed). 33 Jamison DT. Foreword to the global burden of disease and injury series. In: Murray CJL, Lopez AD, editors. The Global Burden of Disease: A Comprehensive ......................................................................................................... The European Journal of Public Health, Vol. 28, No. 4, 778–783 The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckx219 Advance Access published on 16 January 2018 ......................................................................................................... Physical activity, weight and functional limitations in elderly Spanish people: the National Health Survey (2009–2014) 1 2 3 Pedro A. Latorre-Roma´ n , Jose´ A. Laredo-Aguilera , Felipe Garcı´a-Pinillos , 4 2 Vı´ctor M. Soto-Hermoso , Juan M. Carmona-Torres 1 Department of Corporal Expression, University of Jaen, Jaen, Spain 2 Department of Nurse, University of Castilla La-Mancha, Ciudad Real, Spain 3 Department of Physical Education, Sport and Recreation, Universidad de La Frontera, Temuco, Chile 4 Department of Physical and Sports Education, University of Granada, Granada, Spain ´ ´ Correspondence: Jose Alberto Laredo-Aguilera, Av. Real Fabrica de Sedas, s/n, 45600 Talavera de la Reina, Toledo, Tel: +34 690384737, e-mail: jalaredo88@gmail.com Background: The purpose of this study was to analyze physical activity (PA), functional limitations, weight status, self-perceived health status and disease or chronic health problems in older people aged 65 and over using the European Health Survey in Spain (EHSS) conducted one in 2009 and one in 2014. Methods: This study included 12,546 older people, 6026 [2330 men and 3696 women; age (Mean, SD) =75.61  7.11 years old] in 2009 and 6520 [2624 men and 3896 women; age (Mean, SD) =75.90  7.59 years old] in 2014. The sample was divided into three age groups: 65–74 years old, 75–84 years old and 85 years old. Results: In 2014, participants exhibited lower values for moderate PA, and self-perceived health status compared to 2009. Moreover, in 2014 more people with disease or chronic health problems, and severe difficulty walking 500 m without assistance were found and severe difficulty going up and down 12 stairs than people in 2009. In relation to weight status there were no significant differences between older people in 2009 and 2014. Conclusions: From 2009 to 2014, the PA levels of Spanish older people have decreased, while the BMI has not increased. That fact is in consonance with a worst perception of health status in 2014 and with an increase of their disease levels. The current data highlight the importance of incorporating exercise programmes at an early stage of ageing in order to preserve physical per- formance, and to prevent the negative consequences of ageing. ......................................................................................................... associated with increased incidence of type 2 diabetes, cardiovascu- Introduction 7 8 lar disease and risk of falls. estern Europe has one of the world’s oldest populations. In Obesity and physical inactivity are major universal public health Spain, life expectancy is 78.9 years for men and 84.9 years for concerns in older people and physical activity (PA) has shown the women. Ageing has been associated with frailty and functional largest impact on survival, with the strongest inverse relationship limitation due to three factors: an irreversible biological process, between body mass index (BMI) and mortality. Promotion of deconditioning due to a sedentary lifestyle and comorbidity effects. regular PA is one of the main non-pharmaceutical measures Along with ageing, there is impairment in the functional reserve, proposed for older people, who often show a low rate of PA. increasing sensitivity to external aggressions causing fragility, The PA has been widely recommended due to its positive effects sarcopenia, falls, disability and hospitalization, with a deterioration on the maintenance and/or increase in skeletal muscle mass and 4 5 5,11 in quality of life and physical fitness. These decrements have been strength, and in aerobic fitness.

Journal

European Journal of Public Health – Oxford University Press

Published: Aug 1, 2018

Keywords: cost of illness; world health organization; disability-adjusted life years; exercise; disability; spain; estonia; romania; serbia; global burden of disease

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